Medical History Edit
Clancy was the result of in-vitro fertilization. He has had all of his vaccinations. He broke his right ulnar bone when he was three, resulting in the use of a titanium surgical pin in order to hold the bones of his right arm together. He had chicken pox when he was five. He also had a history of alien abduction fantasies.
Case History Edit
The case was brought to Dr. House. Dr. Cameron thought that the combination of rectal bleeding and alien abduction fantasies was most likely due to sexual abuse. However, the emergency room ran a rape kit which showed no evidence of rectal tearing, semen or pubic hair. Dr. Foreman pointed out recent research linked neurological disorders with bleeding disorders. However, Dr. House did not think it was a neurological problem. He thought the alien abduction fantasies were not hallucinations but nightmares. Since nightmares aren't a symptom of any organic disease, he thought it was merely a bleeding problem which indicated either a bleeding digestive tract or another type of bleeding disorder. Dr. House ordered PT and PPT panels and a bleeding time test. He also ordered an endoscopy of his stomach and colon.
Dr. Chase performed the bleeding time test on Clancy by making a small nick on his arm. The patient was worried that the aliens could get in the windows. Dr. Chase reassured the patient, but the patient complained he had a chip in his back and that the aliens inserted a probe between the same two ribs. Dr. Chase pinched the patient's neck to try to convince him he had removed the chip, but Clancy wasn't fooled.
Dr. Chase reported Clancy's alien abduction stories to Dr. House. He was impressed by the level of detail which couldn't be explained by Clancy's interests. The endoscopies were clean. The clotting scans were normal and Clancy's blood clotted in six minutes during the bleeding time test, well within range. However, given the clean endoscopies, the only explanation was a bleeding disorder, so Dr. House thought that Dr. Chase had screwed up the test. He ordered Dr. Foreman to repeat it.
Dr. Foreman repeated the test, and this time Clancy's blood did not clot, forcing Dr. Foreman to stop the bleeding himself after 25 minutes. This confirmed it was a bleeding disorder. When Dr. Chase was confronted with the results, he stated that it was just as likely Dr. Foreman got the wrong result. Dr. Cameron wanted to run further lab work on Clancy's clotting factors to confirm which result was correct. However, Dr. House was convinced that Dr. Foreman's result ws correct.
Later, Dr. Chase went to see the patient and found him missing from his room. He found him in a stairwell trying to use a sharp piece of metal to get the chip out of his back. He was bleeding severely and Dr. Chase started to clean up when he saw a piece of metal just below the skin.
The metal was a piece of titanium, most likely from the surgical pin used to repair Clancy's arm. Dr. Chase tried to argue that the pin was removed six months after it was inserted, and that pieces don't just "break off" given its strength, but Dr. House was convinced the pin was the source of the metal. Dr. Chase also wanted an explanation of how the pin migrated from his arm to his neck. If it had gotten into a vein like Dr. Foreman suggested, it would have wound up in his lungs, not his neck. However, the incident showed that Dr. Chase didn't screw up the bleeding time test - Clancy dug a huge hole in his neck and his blood clotted on its own. Dr. House ordered clotting panels.
Dr. Cameron and Dr. Chase went to seek consent to do further blood panels, and Mrs. Green asked if the problem could be psychological. Dr. Chase assured her that Clancy was not trying to hurt himself, but the mother was worried that his alien fantasies were a symptom of serious mental issues.
Dr. Chase went to draw more blood for testing. The patient was still worried about aliens, and Dr. Chase reassured him. However, while Dr. Chase was taking the blood, the patient started hallucinating and his heart rate went up to 136 with his blood pressure rising to 172/112 and his respiration to 90. Dr. Chase diagnosed pulmonary edema which put him into a hypertensive crisis. He ordered oxygen and an intravenous drip of sodium nitroprusside.
Clancy was moved to intensive care. His systolic blood pressure had settled at 170 and Dr. Chase ordered the staff to lower it slowly to prevent the risk of hypoprofusion of his organs. Dr. House noted keeping his blood pressure that high risked stroke, myocardial infarction and blindness. The patient's kidneys were clean. The lab results for clotting factors came back showing it was a bleeding disorder, Von Willebrand disease. However, even Dr. House had to agree that Clancy was able to clot on his own twice. Dr. Cameron suggested that since the patient was clotting during his hypertensive crisis, the clotting may be related to his blood pressure. They noted that during the first test Clancy was worked up over aliens, and in the stairwell he was worked up over the chip in his neck. It appeared Clancy was suffering multiple hypertensive crises.
Dr. Chase approached the parents for permission to do a transesophageal echo, and explained it was only diagnostic. The parents still thought Clancy had a mental illness. Dr. Chase explained that they had to support Clancy even if they did think he was suffering from mental illness.
The team studied the results of the echocardiogram, first on a monitor in Dr. House's office and found no problems - no structural defects and intact valves. However, Dr. House was not satisfied and went to use the high definition monitor in the chapel. However, even that showed no masses, clots or tears. Finally, they went to use a large format projection screen in a lecture hall. Dr. House finally noticed part of Clancy's heart was not beating. Dr. Chase thought he was referring to an arythmia, but it was instead a part of the heart with no rhythm whatsoever. He ordered a heart biopsy of the affected area.
The biopsy showed the DNA from the biopsy site was different from Clancy's DNA. They started a new differential, and Dr. Foreman noted that DNA can become mutated by things like extreme ultraviolet radiation, but the patient showed no sign of tanning that UV would cause. Dr. Cameron suggested nitrous acid or ethidium bromide exposure. Dr. Chase suggested a mutagenic fungus. Dr. Foreman suggested an environmental scan. However, Dr. Chase suggested knowing the cause was unimportant - what was important was treating it, probably with surgical removal. However, Dr. Cameron noted that the foreign DNA was probably elsewhere. Dr. Foreman agreed - they were lucky to find the foreign cells in his heart. Dr. Cameron did come up with an idea - tagging the foreign DNA, allowing it to diffuse through the body and then creating an antibody to the proteins that would bind with them and light them up in scans. Dr. House agreed.
They tagged the foreign DNA and put Clancy in an MRI. They found several areas lighting up, like bone marrow in his leg bone that explained the bleeding problems. They also found more cells in his heart which would cause more hypertension if they missed them. They also found cells in his eye which explained why he needed glasses. However, there were no foreign cells in his brain, which indicated that the alien abduction fantasies were nightmares and not a neurological problem.
The patient had surgery to remove the foreign cells. His prognosis was excellent and he was expected to have a full recovery.
Dr. Chase examined Clancy after the procedure, and his sight had improved to the point he didn't need glasses. They planned to release him the next morning.
However, that night, Clancy had another alien abduction nightmare, resulting in a seizure. Dr. Chase ordered clonazepam. This appeared to mean there was still foreign tissue somewhere inside Clancy. The seizure indicated it was most likely a problem in the temporal lobe and it was a neurological problem. Dr. House thought that the tag hadn't penetrated the blood-brain barrier and allowed them to see the foreign cells. He ordered the tag injected into the brain. However, the tag did not light up any cells in the brain, which seemed to rule out a neurological disorder again. However, Dr. Foreman pointed out the symptoms were neurological so it had to be a brain problem. Dr. House surmised that there was foreign DNA in his brain, but the tag wasn't working there. Brain tissues do express different proteins. However, they were at a loss as to how to find the foreign tissue.
Eventually, Dr. House could come up with no new idea. He wanted to make sure the patient's blood pressure was normal and release him. Dr. Chase objected because the seizure could indicate they hadn't fixed the underlying problem. Dr. House was sure the hypertension and bleeding problems were fine. The seizure could be an indication of epilepsy. In any case, they had found all they could. They had to wait for him to show new symptoms.
Dr. Cuddy confronted Dr. House about dropping the case, but the only thing that he could think of was to totally remove the affected body parts. He was surprised when Dr. Cuddy considered it. He realized that Dr. Cuddy had been holding something back, and she finally admitted that she had lied to him about his previous case. Dr. House made a joke about her fetus not having a daddy, when he realized that Clancy's problems could be rooted in his in-vitro fertilization. He surmised that two embryos were implanted into his mother's womb and they merged early in development - chimerism. The DNA from the suppressed embryo was interfering with his body's other functions. He explained to the parents that the suppressed embryo was having actual thoughts in Clancy's brain which were causing the alien abduction episodes. He suggested using an electric probe on Clancy's brain that would stimulate cells that would induce a hallucination. That would indicate where the foreign cells were and they could destroy them. Despite the risks, the parents agreed.
The problem was explained to Clancy and he was prepared for surgery. Dr. Chase showed him cards with pictures on them and Dr. House stimulated parts of his brain while Dr. Foreman noted his reactions and directed the probe. Finally, Clancy saw lights and his EEG showed he was hallucinating, but there were no dark spots on the functional MRI to indicate where the foreign cells were. Clancy's blood pressure started to get dangerously high. Dr. House ordered more voltage, but still no dark spots appeared. When he had reached maximum voltage, Dr. House deliberately played to the hallucination to make it more vivid. The fMRI showed where the foreign brain cells were and Dr. House started to remove them. Eventually, Clancy stopped hallucinating and realized the aliens were gone. Dr. House ordered the surgical staff to close the incisions.